Health Justice Now: Single Payer and What Comes Next

WHY SINGLE PAYER AND WHAT IS HEALTH JUSTICE? BEHIND THE BOOK WITH AUTHOR TIMOTHY FAUST

American health finance is currently a multi-payer model—there are many different insurers (or “payers”) who represent a fragment of the population. “Single payer” refers to a health finance model in which all insurers are consolidated into one public entity—a single payer. This is more or less mappable to “Medicare for All,” if a little more precise.

I can tell you hundreds of benefits to single payer being enacted in this country… 272 pages’ worth! In short, though: 1) single payer protects us from medical bankruptcy caused by the arbitrary and unequal allocation of suffering into which we are born; 2) single payer lets us seek healthcare when we need it, instead of turning our bodies into time bombs; 3) single payer unshackles us from the domination of employers and domestic partners who control our and our children’s access to healthcare; and 4) single payer finally forces a single actor—the public insurer—to bear the costs of providing care, as well as the costs of what happens when care is not provided. It is a first lever against broader inequity in America.

The ACA is a mixed bag. A lot of people have received essential insurance from it—mostly through Medicaid expansion. But about as many people have purchased, through the ACA, insurance plans with byzantine subsidy regulations tied to minutiae of income reporting, which can be a real pain if you work an hourly or irregular job. And with increasing medical costs every year shifted onto customers through copays and high deductibles, many people who got insured through the ACA can’t afford to use that insurance—42% of people in the ACA pool are considered “underinsured.” This “uninsured-ness” is growing among people who get insurance from their employers as well—affecting 28% of that population in 2018.

All of this is to show that the fragmented multi-payer model is fundamentally incapable of doing what it needs to do, and cannot be coaxed or massaged into providing adequate insurance or backing the promise of health for all people in America.

That’s a buck-wild effort to scare away single payer, considering that thirty hospitals—most of them rural—close annually in the United States. They close because the patients they serve are uninsured, and therefore can’t pay their bills; without those payments, the hospital folds. Guaranteeing insurance for all patients helps rural hospitals, or hospitals which treat sick or poor patients, keep the lights on. Medicaid expansion, for example, reduces the rate of hospital closures by six times the frequency of what happens in states without expansion.

Sometimes. Not always. And not in the way critics of single payer like to pretend. In that vein—often, someone will say something like, “oh, private insurance and public insurance can co-exist, like they do in Germany,” which neglects to mention that German regulation of insurance companies is a world apart from American policy. In Switzerland or the Netherlands, the public is all but forced to purchase supplemental private insurance, which need not abide by some of the most crucial consumer protections baked into their respective primary healthcare markets—like being able to reject applicants based on health status. During the recession, Swiss people unable to afford their supplemental insurance premiums watched as their government came to the rescue of their insurers by giving them permission to cut off defaulters’ contracts. Not an outstanding role model.